Introduction and question Contrast-enhanced ultrasound is a proven method for the characterization of benign and malignant liver masses and also for metastasis detection in the context of staging and follow-up of oncological patients. Nevertheless, the current German S3 guideline calls for a dwMRI of the liver to rule out metastasis in the case of a potentially resectable pancreatic tumour. PET-CT but not CEUS is recommended as an alternative. The aim of the study was to compare CEUS, ceCT and dwMRI in metastasis detection prior to pancreatic/Whipple resection in the case of suspected cancer.

Children are often treated off-label and are at a disadvantage in pharmacotherapy. The aim of this study was to implement and evaluate a quality assurance measure (PaedPharm) for pediatric pharmacotherapy whose purpose is to reduce medication-related hospitalizations among children and adolescents.PaedPharm consisted of the digital pediatric drug information system PaedAMIS, pediatric pharmaceutical quality circles (PaedZirk), and an adverse drug event (ADE) reporting system (PaedReport). The intervention was implemented in a cluster-randomized trial (DRKS 00013924) in 12 regions, with a pediatric and adolescent medicine clinic in each and a total of 152 surrounding private practitioners, in 6 sequences over 8 quarters. In addition to the proportion of ADE-related hospital admissions (primary endpoint), comprehensive process evaluation included other endpoints such as coverage, user acceptance, and relevance to practice.41 829 inpatient admissions were recorded, of which 5101 were patients of physicians who participated in our study. 4.1% of admissions were ADE-related under control conditions, and 3.1% under intervention conditions (95% CI: [2.3; 5.9] and [1.8; 4.5], respectively). A model-based comparison yielded an intervention effect of 0.73 (population-based odds ratio; [0.39; 1.37]; p = 0.33). PaedAMIS achieved moderate user acceptance and PaedZirk achieved high user acceptance.The introduction of PaedPharm was associated with a decrease in medication-related hospitalizations that did not reach statistical significance. The process evaluation revealed broad acceptance of the intervention in outpatient pediatrics and adolescent medicine.

Multi-frequency processing (MFP) leads to enhanced image quality (IQ) of radiographs. This study is to determine the effect of third generation MFP (M3) on IQ in comparison to standard second-generation MFP (M2). 20 cadavers were examined and post-processing of radiographs was performed with both M2 and M3. Three readers blinded to the MFP used for each image independently compared corresponding image pairs according to overall IQ and depiction of bony structures and soft tissue (+ 2: notably better > 0: equal > − 2: notably worse). A significant deviation of the median grade from grade 0 (equal) (p < 0.01) for each evaluator A, B and C speaks against an equal image quality of M2- and M3-images. M3-images were categorized with better grades (+ 1, + 2) in 87.7% for overall image quality, in 90.4% for soft tissue and 81.8% for bony structures. M3 images showed significant higher averaged SNR and CNR for all investigated lower extremities than that of M2 images (0.031 < p < 0.049). The newest generation of MFP leads to significantly better depiction of anatomical structures and overall image quality than in images processed with the preceding generation of MFP. This provides increased diagnostic accuracy and further decreased radiation exposure.

Purpose or Learning Objective: Intra-articular foot infiltrations can be performed as a diagnostic but also as a therapeutic option for pain relief in conditions such as osteoarthritis or impingement. Our purpose was to correlate magnetic resonance imaging (MRI) findings with immediate outcomes after intra-articular foot infiltrations.

Nahezu jeder Notfallpatient, der sich zur Abklärung seiner Beschwerden in einer Notaufnahme vorstellt, erhält eine diagnostische Bildgebung. In vielen Notaufnahmen wurden gemeinsam mit den radiologischenAbteilungen „StandardOperatingProcedures“ nach aktuellenFachempfehlungen erstellt und fortwährend interdisziplinäraktualisiert, umdieDiagnostik inArtundUmfangadäquatdurchzuführen. Bei zeitkritischemHandlungsbedarf bedeutet dies, möglichst schnell und präzise die für das weitere Vorgehen relevanten Informationen zu erhalten. In vielen Kliniken werden deshalb beispielsweise Patientenmit Polytrauma, Schock, Schlaganfall, akutemAortensyndromoderSepsis priorisiert und erhalten leitliniengerecht umgehend die für ihre Fragestellung notwendige bildgebende Diagnostik. Dieses Vorgehen hat sich bewährt – so steht etwa bei Patientenmit Polytrauma fest, dass durchdiesesVorgehendieSterblichkeit signifikant reduziert wird.

Introduction Lung ventilation is a standard sign of life in newborns. Post-mortem computed tomography (PMCT) is highly sensitive to the presence of gas in the body including the lungs. Current standard examinations to determine the pulmonary ventilation status in newborns are the flotation test and histology. The purpose of this study was to compare the accuracy of PMCT with the flotation test for determining the lung ventilation status with histological control as reference standard. A cut-off value as CT number in Hounsfield Units (HU) determining lung ventilation of newborns in PMCT should be established. Methods A total of 38 infant lungs were examined of which 21 lungs were from infants deceased shortly after live birth (control group) and 17 lungs belonged to infants where live birth was in question (study group). All lungs were examined using PMCT, flotation test, and histological examination. Results The control group showed an overall mean attenuation ± standard deviation of −219 HU ± 135; the study group of 45 ± 15 HU in histologically nonventilated lungs versus −192 ± 207 HU; ( p < 0.001) in ventilated lungs. The best cut-off value for optimal discrimination of ventilated and nonventilated lungs in newborns was −35 mean HU. Conclusion PMCT is equally well suited to determine lung ventilation as the flotation test. It provides additional information regarding pulmonary infiltration, degree of putrefaction, or signs of trauma (fractures, pneumothorax). Histology remains mandatory in ambiguous cases.

In recent phantom studies low-contrast detectability was shown to be independent from variations in tube voltage in digital radiography (DR) systems. To investigate the transferability to a clinical setting, the lower extremities of human cadavers were exposed at constant detector doses with different tube voltages in a certain range, as proposed in the phantom studies. Three radiologists independently graded different aspects of image quality (IQ) in a comparative analysis. The grades show no correlation between IQ and kV, which means that the readers were not able to recognize a significant IQ difference at different kV. Signal-to-noise and contrast-to-noise ratios showed no significant differences in IQ despite the kV-setting variations. These findings were observed from a limited kV range setting. Higher kV-settings resulted in lowest patient exposure at constant IQ. These results confirm the potential of DR-systems to contribute to standardization of examination protocols comparable to computed tomography. This may prevent the trend to overexpose. Further investigations in other body regions and other DR-systems are encouraged to determine transferability.

Clinical problem The indication for resuscitation room care is an acute (potentially) life-threatening patient condition. Typical causes for this are polytrauma, acute neurological symptoms, acute chest and abdominal pain or the cause remains unclear at first. The care is always provided in a suitably composed interdisciplinary team. This requires cause-specific standards tailored to the care facility and requires a mutual understanding of the partners involved with regard to specialist interests and care processes. Standard radiological methods Whole-body CT is established for polytrauma imaging and usually each institution has already defined an institutional standard. For the other causes, first imaging with CT is just as common, but the protocols and procedures to be used are often not as clear as in the case of polytrauma. Methodical innovation and evaluation For polytrauma service, ATLS and procedures according to ABCDE already serve as a largely standardized framework in the resuscitation room. For every other group of causes, comparable concepts should be developed and institutionally strive for objectification of continuous improvement. This refers not only to the resuscitation room stay but also to the interfaces before and after resuscitation room service. Practical recommendations After the patient has arrived, it has to be determined whether the assessment of a vital risk is retained. If so, institutionally defined care standards must be followed for the various causes. This concerns the interface logistics, the definition of a team leader including associated tasks, the supply processes including the CT examination protocols as well as the close communication.

Purpose: Conventional mammography is a decisive tool in detecting breast cancer. Continuous efforts are undertaken in order to further improve the image quality as well as to reduce the applied doses. The purpose of our study was to compare diagnostic image quality of dose reduced computed mammography with a new needle-based detector system to full dose powder imaging plates. Methods: We retrospectively compared 360 randomly chosen mammographies performed on a GE Senographe DMR running the Agfa DX-M needle-based imaging plate system (NIP) with their preliminary examinations which were acquired at standard dose with the same GE mammography device and an Agfa CR85-X powdered storage phosphor imaging plate system (PIP). NIP-based mammographies were about 29.8 % dose-reduced. The preliminary examinations had to be performed not earlier than 2 years before the recent investigations. Exclusion criteria were changes in ACR level and appearance of the scored targets and not optimally positioned and exposed mammographies. The images were blinded and read separately twice by 2 mammography experts according to a 3-point score on diagnostic image quality and the visualization of parenchyma, cysts, fibroadenomas, physiologic lymph nodes, solitary microcalcifications and macrocalcifications. Results: Dose reduced NIPs showed a significantly better visualization of parenchyma at ACR II/III and solitary microcalcifications at ACR I-III mammographies (p< 0.001) whereas the difference in scoring macrocalcifications, cysts, fibroadenomas and physiologic lymph nodes was not significant. The reading showed an excellent intra- (r= 0.97/0.94) and interobserver agreement (r= 0.92). Conclusion: With computed mammography using the needle-based detector system a significant dose reduction is possible without loss of diagnostic image quality.

Klinisches Problem Die Indikation für eine Schockraumversorgung ist ein akut (potenziell) lebensbedrohlicher Patientenzustand. Typische Ursachen hierfür sind Polytrauma, akute Neurologie, akuter Brust- und Bauchschmerz oder eine unklare Genese. Die Versorgung erfolgt immer in einem interdisziplinären Team. Dies erfordert ursachenspezifische und auf die Versorgungseinrichtung abgestimmte Standards und setzt ein gegenseitiges Verständnis der beteiligten Partner hinsichtlich fachspezifischer Interessen und Versorgungsabläufe voraus. Radiologische Standardverfahren Für das Polytrauma ist die Ganzkörper-Computertomographie (CT) etabliert, für die in aller Regel auch ein institutioneller Standard definiert ist. Für die anderen Ursachen ist eine erste CT-Bildgebung ebenso üblich, aber die zu verwendenden Protokolle und Abläufe sind oft nicht so eindeutig wie im Polytraumafall festgelegt. Methodische Innovation und Bewertung Für ein Polytrauma ist der Schockraumversorgung mit ATLS® („Advanced Trauma Life Support“) und einem Vorgehen nach ABCDE ein weitgehend standardisierter Rahmen vorgegeben. Für jede andere Ursachengruppe sollten vergleichbare Konzepte entwickelt und institutionell eine kontinuierliche Verbesserung angestrebt und objektiviert werden. Das bezieht sich nicht nur auf den Schockraumaufenthalt, sondern auch auf die Schnittstellen davor und danach. Empfehlung für die Praxis Nach Patientenankunft ist festzulegen, ob die Einschätzung einer Vitalgefährdung beibehalten wird. Falls ja, sind vorher für die verschiedenen Ursachen institutionell definierte Versorgungsstandards einzuhalten. Dies betrifft die Schnittstellenlogistik, die Definition einer Teamleitung einschließlich zugehöriger Aufgaben, die Versorgungsabläufe inklusive der CT-Untersuchungsprotokolle ebenso wie die enge Kommunikation. Clinical problem The indication for resuscitation room care is an acute (potentially) life-threatening patient condition. Typical causes for this are polytrauma, acute neurological symptoms, acute chest and abdominal pain or the cause remains unclear at first. The care is always provided in a suitably composed interdisciplinary team. This requires cause-specific standards tailored to the care facility and requires a mutual understanding of the partners involved with regard to specialist interests and care processes. Standard radiological methods Whole-body CT is established for polytrauma imaging and usually each institution has already defined an institutional standard. For the other causes, first imaging with CT is just as common, but the protocols and procedures to be used are often not as clear as in the case of polytrauma. Methodical innovation and evaluation For polytrauma service, ATLS and procedures according to ABCDE already serve as a largely standardized framework in the resuscitation room. For every other group of causes, comparable concepts should be developed and institutionally strive for objectification of continuous improvement. This refers not only to the resuscitation room stay but also to the interfaces before and after resuscitation room service. Practical recommendations After the patient has arrived, it has to be determined whether the assessment of a vital risk is retained. If so, institutionally defined care standards must be followed for the various causes. This concerns the interface logistics, the definition of a team leader including associated tasks, the supply processes including the CT examination protocols as well as the close communication.

Purpose To objectify effects of an anatomical viewing scheme on the respective correctness of (a) findings, (b) interpretations, and (c) self-assessments of readers in chest radiographs acquired in one plane and the assessment of other influencing factors. Materials and methods In all, 20 radiologists with 3-60 months of full-time radiography experience evaluated 12 chest radiographs of varying difficulty: once with and once without using an anatomical viewing scheme with at least 1 month in between (n & x202f;= 480). In consensus of 3 radiological experts (a) and (b) were determined by means of a current computed tomography. The self-assessment (c) of readers was queried. Results (a) Findings were either missed or not described in 21%. Another 20% were recognized, but incorrectly described, (b) 62% of interpretations and 31% of derived clinical consequences were wrong and (c) in 39% of items the readers overestimated themselves. Experts were faster and better than novices, but for the scheme usage no further significant differences were detected (p & x202f;> 0.5, respectively). The most pronounced effect was found in comparison with the routine report produced by the joint evaluation of novices and experts being clearly superior even to the expert study results (a), (b) and (c) alone (p & x202f;< 0.001, respectively). Conclusion Reporting of chest X-rays acquired in one plane was often incomplete or even wrong, and the evaluators overestimated themselves, which was not influenced by the use of the anatomical viewing scheme. Since errors between the evaluators sometimes differed greatly, duplicate evaluation of the radiographs by two different radiologists, which is already the case in many training facilities, may possibly be advisable in general.

Background and Purpose- Recent studies show that mechanical thrombectomy of acute basilar artery occlusions (BAO) results in high rates of successful recanalization and good outcomes, but predictors are not completely established yet. Varying occlusion types may benefit differently, and especially, an underlying basilar stenosis (BS) seems to have an impact. Aim of this study was to investigate angiographic and clinical differences in BAO subtypes and to test the potential of perviousness measures for a preinterventional identification of clinically relevant different occlusion types. Methods- All consecutive patients with acute BAO, endovascular treated at a single comprehensive stroke center, were included. Different occlusion patterns, especially underlying BS, were identified and analyzed in respect of angiographic and clinical (National Institutes of Health Stroke Scale/modified Rankin Scale) outcome parameters (N=115). Thrombus perviousness measures (change in thrombus attenuation Δt and corrected void fraction ε) were assessed in admission computed tomography imaging and correlated to different etiological subgroups. Results- Despite comparable rates of successful recanalization (87% for BAO with BS versus 95% without BS), the BS group showed worse clinical outcome with higher National Institutes of Health Stroke Scale/modified Rankin Scale values (P=0.002/0.003). The group of BS turned out to have lower thrombus density values in unenhanced scans (mean, 42.0 Hounsfield units) and higher perviousness measures Δt (mean, 34.6 Hounsfield units) and ε (mean, 0.23) than thrombi without an underlying BS (mean, 53.6 Hounsfield units/13.1 Hounsfield units/0.08, P=0.01/ 0.004/ 0.001). Conclusions- In agreement with previous studies, outcome of mechanical thrombectomy of BAO seems to depend on pathogenesis with less clinical benefit for underlying BS, raising the question of early identification of this subgroup. Perviousness showed a high potential to differentiate acute BAO with and without BS, possibly usable as an admission imaging marker for BS.

Clinical issue Both the progress of surgical techniques and the demographic development with increasing numbers of multimorbid patients demand and also encourage radiology in the setting of trauma and acute emergencies. In addition to a fast and precise diagnostics, this also includes image-guided, minimally invasive therapy to control and treat several acute pathologies. Standard radiological procedures Computed tomography (CT) is not only important for the diagnosis of abscesses, active bleeding or other acute pathologies, but also allows minimally invasive therapy. While digital subtraction angiography (DSA) guides catheter-based procedures, e.g., to control bleedings or to place percutaneous transhepatic cholangiodrain (PTCD), fluoroscopy allows the 3D-visualization to drain abdominal and thoracic abscesses. Methodological innovation and evaluation Radiology has established itself in the treatment of acute emergencies or acute complications through gentle and usually fast minimally invasive procedures. Presumably, MRI interventions will become increasingly important in the near future and, thus, complement the portfolio. Practical recommendations Every clinical radiologist who works on night shifts should be able to safely carry out some basic interventional techniques in order to stabilize the patient and at least ensure medically safe bridging to the next routine workday. Due to the diversity of materials and the rarity and difficulty of some procedures, the full portfolio requires years of expertise and will therefore remain restricted to specialized interventional radiologists.

A Correction to this paper has been published: https://doi.org/10.1007/s00330-020-07520-2